Running head: NURSING CARE PLAN II

Nursing Care Plan II
Maria Milazzo
Cochise College
Nursing 123
April 16, 2010
Maxine Parmley RN, MSN

Nursing Care Plan II
Setting and Demographics
My scheduled clinical rotation at Life Care Center began on April 8th. Mrs. X, a long-term resident, was the patient I had chosen. I had conducted several patient interviews and she appeared to be an interesting patient. After passing out the morning medicines to the resident’s, I made my way down the hall to Mrs. X’s room. When I arrived to Mrs. X’s room she was quietly sleeping in her bed with a book titled the “Autobiography of Hilary Clinton” on her stomach. I knocked on the door and proceeded to greet her and introduce myself, she sat up, smiled, and said she loved visitors. I explained my school assignment to Mrs. X , and requested permission, and perform a physical assessment she stated, “ it was quite alright.” She is a hispanic ninety one year old woman, approximately five feet five inches tall, and weighs 98 pounds; she has been a resident of Life care for eight months. Her current diagnoses included a closed ulnar fracture with rehabilitation, atrial fibrillation, and coronary artery disease. Her secondary diagnoses are hypothyroidism, depressive disorder, hypertension, esophageal reflux, generalized pain, and chest pain.
Functional Health Patterns
Health Perception-Health Management:
Subjective:
Patient stated her general health has been declining recently, with three colds within the last year, one being severe. She also stated she has not been able to function normally because of her health. The patient had been immunized for influenza in September of 2009 but does not recall any recent immunizations. She is not allergic to any foods or medications, and has never received a blood transfusion. She began smoking fourteen, but quit smoking thirty years